Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

Saturday, March 31, 2012

I wouldn't have wanted to give the impression in my last blog post that misogyny is something rare in the fields of HIV and public health, or that it is confined to Uganda, high HIV prevalence countries or even Africa. A good deal of HIV programming in African countries over the years has been noticeably racist, particularly in the assumption, overt or covert, that HIV is almost always heterosexually transmitted. But a lot is also misogynistic, and little effort is made to conceal this.

Mass male circumcision campaigns are ostensibly aimed at reducing HIV transmission from females to males. It is unlikely to achieve this aim; the extent to which circumcision could possibly influence transmission is almost certainly very low and would be rendered lower still if sexual behavior were to change as a result of circumcision. For example, men, and even more so women, think circumcised men are unlikely to be HIV positive. Circumcision is even being offered to HIV positive men; and many HIV positive men happen to be circumcised already.

People behaving as if circumcision reduces HIV transmission, whether through dishonesty or ignorance, will result in risks for women increasing. Yet, African women are a lot more likely to be infected with HIV than men. The recent Aids Indicator Survey which found that HIV prevalence is increasing in Uganda also showed that prevalence is a lot higher in women. This is also the case in other African countries; in some tribes, female prevalence can be manytimes higher than male prevalence.

There has been a lot of discussion recently about Depo Provera and other injectable hormonal contraceptives which, research has suggested, may increase transmission from males to females and also from females to males. WHO did some well publicized humming and hawing, though those doing the discussing were sworn to secrecy. But it was decided that women in high HIV prevalence countries should continue using Depo Provera and the like (curiously, women in low HIV prevalence don't tend to use injectable Depo Provera), as long as they use condoms at the same time. Yet, such contraceptive methods were originally sold to people in developing countries on the grounds that condoms were unlikely to be used.

Some of the excuses for continuing to use injectable hormonal contaceptives included worries about women having unplanned pregnancies, suffering injury or death during childbirth, or concerns that the infant will be injured or die. However, increasing contraceptive use does not, on its own, improve maternal or infant health. Only improvements in health facility conditions, increases in the numbers of trained and well-equipped health professionals and greater accessibility to safe health services will reduce maternal and infant morbidity and mortality.

One of the most affected groups in the history of the HIV pandemic in Africa has been sex workers, or those thought to be involved in sex work. But it is still unclear how such high rates of HIV transmission seen in the 80s and 90s ever came about. Sex workers in non-African countries don't appear to face anywhere near the same risks unless they are also intravenous drug users. As sex workers have been systematically rounded up for testing and treatment for sexually transmitted infections since long before HIV was identified, it is even possible that HIV was inadvertently spread through the reuse of unsterile equipment. After all, up until some time in the 1980s, reuse of unsterile equipment was common in many countries. It is still not known how common it is in very poor countries today.

Another group that has suffered, and continues to suffer shockingly high HIV transmission rates is pregnant women. But they may, like sex workers, also face what could be serious non-sexual risks. Pregnant women in urban areas (prevalence, like health facility attendance, are low in rural areas) tend to receive a lot of medical care, such as vaccinations and various other services. Instead of wondering how so many women, often with only one HIV negative partner, become infected with HIV during their second or third trimester, or even in a few weeks or months after giving birth, it is assumed that they continue to have unprotected sex, and not just with their main partner, either.

In addition to showing that women are more likely to be HIV positive than men, these surveys carried out regularly in African countries always show that some men have far more sex than most women and that men are far more likely to engage in 'unsafe' sex than women. However susceptible women may be to HIV compared to men, it is even clearer that HIV transmission is unlikely to be mainly heterosexually transmitted. It's time to look more closely at the non-sexual risks people face, especially those routinely faced by many women. In fact, if you remove men infected through male to male sex and intravenous drug use (the latter being more likely to affect men than women), the ratio of female to male HIV prevalence is even more stark.

So where does the misogyny come in? Well, stories about half empty soda bottles without caps, snakes in holes, cows in fields and much of the rhetoric associated with HIV transmission seems to find willing, though uncritical recipients. 'Targeting' women and groups that are all or mostly made up of females may reinforce the belief that HIV affects women more than men, especially given higher prevalence figures among women. Moralizing accounts of HIV and 'explanations' of transmission also seem to point the finger at women who tempt men, who get pregnant, who spread diseases; while certain male groups are also targeted, one can often get the impression that sex, and therefore HIV, are primarily the preserve of women.

Hunsmann's research was carried out at a time when there was a lot of HIV money coming into the country. But contrary to what one may have expected, cost-effectiveness of interventions was not a high priority. And it was assumed that structural interventions were not cost-effective, without there being much evidence for this. Different groups carved out their chosen niches and lobbied for continued funding, but structural interventions were not among those concerns.

The facts that structural interventions may be longer term and have an impact that goes way beyond HIV alone may sound like advantages; but they don't tend to attract money that feeds short term interests and concentrates on something as worthy of public attention as sex and sexually transmitted diseases. Structural interventions that might address gender inequities, access to health services, less fashionable health and other issues, many of which long pre-date HIV, have not attracted much attention or funding and they continue to be ignored now that funding is becoming more scarce.

The obsession with sexually transmitted HIV often highlights some of the background structural factors involved in HIV epidemics. But those structural factors do not attract anything like the attention or funding that many relatively ineffective interventions receive. Western HIV funding has tended to be highest where HIV has been presented as a matter of sexual behavior, often with the implication that women play a more significant role in transmitting the virus. And funding has been lowest for interventions that may most successfully address such prejudices. Western backed programs may draw attention to these issues, but far from addressing them, they may be exacerbating some of the more acute pre-existing problems rather than alleviating them.

However, it has never been clear what Museveni 'did'; it has been shown that ABC didn't exist as a strategy in the late 1980s and early 1990s, when Museveni was supposed to have been working his magic. It has also been shown that, even if the word 'abstinence' ever played any role at that time, it is very unlikely that it had much effect on HIV transmission. In fact, even condom use was not very common in the 80s and 90s, nor was Museveni very enthusiastic about condom use. And that was before his wife took up the cudgel against condoms, presumably with some funding from the fundamentalists who later supported the inhumane anti-gay legislation still being discussed in the country.

There may have been other factors, but why should they all have related to sexual transmission of HIV? Slutkin and colleagues barely mention non-sexual HIV transmission, except to cite some sources which recount a campaign that included measures “to reduce transmission through blood transfusion by setting up laboratories to test all blood before transfusion and to reduce transfusion to a minimum” and “to advocate careful sterilization of instruments and contaminated hospital areas to assure patient and health worker safety”. But perhaps that was it; non-sexual transmission would have then dropped to a very low level. Sexual transmission may have dropped a bit, but is unlikely to have dropped enough to explain the massive drops that were seen in Uganda after prevalence peaked.

Things are very different now. while HIV incidence is a lot lower than it must have been before the initial peak in prevalence in the 80s, it is still high enough to drive prevalence up, rather than allowing it to flatline. More and more people are now receiving treatment for HIV, which means that more are living with the disease, which may explain some of the increase in prevalence. But what accounts for various drops in incidence, the annual rate of new infections, and for the current increase? Is it really changes in sexual behavior?

Balyeku feels we need to "revisit the strategies which were used in the mid-1980s and early 1990s that led to a sharp decline in the prevalence rates". But it is almost certain that many of the people who are infected now, and those who are becoming infected, were recipients of Museveni's 'messages'. Maybe some of Museveni's messages were not as powerful as Balyeku and others seem to imagine? Or perhaps they were all too powerful, but still don't explain drops in sexual transmission of HIV?

We are told that the president "would address [schoolchildren] with two bottles of soda to illustrate his teachings. One bottle would be full of soda with its bottle top cover intact while the other would be half empty with no bottle top. On demonstrating the two soda bottles to the children, the President would ask a child to pick any of the two bottles he or she would prefer to take. All the children pointed at the sealed bottle which was full of soda ignoring the opened one which they were not sure whether it wasn't contaminated. In that analogy, the President's message to the children was that abstinence was the best way for them as they concentrate on their studies."

It's hard now to imagine what the president's 'analogy' was, but it sounds very misogynistic to me. Balyeku goes on: "The second analogy the President used was in comparison to a snake that lives in a hole. He locally referred to the hole as mpompogoma. To him, AIDS is like a poisonous snake that lives in a hole. He advised that the moment you carelessly insert your hand or finger into that hole, you would be luring the poisonous snake to bite. He thus counselled the public to desist from trying these mpompogoma or least snakes bite them. With this analogy many people realised the option of protective sex especially the use of a condom." Does Museveni do it differently, or have I been getting it wrong all these years?

These reminiscences are difficult to square with Slutkin's findings. I wonder how many other 'messages' were made up later, reinterpreted later or entirely misunderstood by their audience. Slutkin writes about the constantly mentioned 'zero grazing' campaign. To people from a rural background, this might refer to feeding animals, especially cattle, food substitutes so they don't need to graze. Slutkin and others interpret it differently, saying it alludes "to the traditional way cattle were fenced in, or tied to a stick to limit grazing outside their own pasture." Does it carry a clear message of 'fidelity', as Slutkin claims? He also remembers posters depicting a cow in a pasture surrounded by a fence. Am I being too literal in also seeing this as misogynistic?

Perhaps I'm imagining things but my interpretation of the above, and other accounts, is that it is either fairly unclear how HIV spread, peaked, declined and subsequently increased in Uganda, and perhaps elsewhere, or that there is a strong disinclination to admit that HIV transmission is about a lot more than just sex. If the Ugandan epidemic was never entirely driven by sexual behavior, it was never entirely 'reversed' (Slutkin's term) by changes in sexual behavior, and the recent increase was also probably not caused by changes in sexual behavior either. The relative contributions of sexual and non-sexual modes of transmission in Uganda and other African countries need to be established before we can hope to reverse any epidemics successfully.

The main risks examined are sexual risks, though there is brief reference to the fact that intravenous drug use may drive or exacerbate HIV transmission. This is surprising considering that sex workers in some of the countries studied must face considerable non-sexual risks, perhaps not only from intravenous drug use. Yet health facilities, especially in low income countries, are not safe places.

There is even fairly direct evidence from publications such as Service Provision Assessments and similar documents, some of which are researched and published regularly and are publicly accessible. These show that equipment to ensure safety in health facilities is often in short supply, or completely unavailable, that staff, who are also in short supply, often lack training and/or awareness of infection control procedures and that protocols for infection control are often unavailable or unused.

But sex workers and their clients, or those assumed to be sex workers and clients of sex workers, may have additional exposure to potentially unsafe healthcare. Since before HIV was identified, these groups were the targets of STI treatment programs. There is additional indirect evidence of non-sexual exposure where HIV positive infants have been identified whose mothers are not infected, women without any sexual risks have been infected although their partners are uninfected and population based surveys, such as the Demographic and Health Surveys, have shown that there quite significant numbers of people who are HIV positive despite having no identified sexual risks.

It's bad enough that HIV may be transmitted in health facilities and through other non-sexual routes; but the biggest worry is that people are not being warned of these possibilities. They don't know what to watch out for in health or cosmetic facilties, whether they are being vaccinated, treated, visiting an antenatal clinic, having an operation, going to a dentist, getting a tattoo or pedicure or even being circumcised on the grounds that it may give some protection to men against HIV infection.

Indeed, when people in African countries are tested for HIV and found to be positive, it is generally assumed that they were infected sexually, despite all the other ways they could have been infected. If, upon being asked about their sexual exposures, they report none, they tend not to be believed. The report on adverse events in hospitals mentioned above notes that the hospitals involved in the study were likely to be among the best available in those countries and that, for a variety of reasons including poor record keeping (here's a photo of a hospital filing system taken in Northern Tanzania), the reported rate of 8% "probably represents an underestimate of the true rate".

It is quite extraordinary that sex workers in Africa have been so much studied, yet their non-sexual risks for HIV have been ignored, despite all the evidence that HIV is not always sexually transmitted. HIV rates among sex workers in some countries are exceptionally high. But, as the report on sex work above finds, in other countries rates are very low. Often where rates are high, they can be accounted for by intravenous drug use. So why should HIV transmission be so high among sex workers in some African countries, and why should we believe it is mostly sexually transmitted? How can health facility transmitted infections be ruled out until this issue has been properly investigated?

Uganda was probably the first African country to receive aid money for HIV programs, for all the good it has done. The 'comprehensive knowledge' people are said to require is mainly about heterosexual HIV transmission, condoms, rejecting 'misconceptions', etc, with little or nothing ever being mentioned about non-sexually transmitted HIV, such as that from unsafe healthcare or cosmetic practices like tattooing, body piercing and manicures.

The upshot is that one third of women have the 'knowledge' and only just over 40% of men do. A lot of research has shown that 'knowledge' about sexual behavior, what's said to be safe and what's said to be unsafe, does not in any obvious way translate into people only engaging in 'safe' sex and always avoiding 'unsafe' sex; often, it's quite the contrary. While many have been taught what to say when asked about HIV, or to take a stab at answering a handful of questions, this has had little effect on behavior and probably none at all on HIV transmission rates.

But if one of the HIV industry's insights is that people are illiterate, then perhaps randomised controlled trials of the sort that have been popular in African countries are not particularly appropriate. Are they even ethical? How can someone give informed consent under such circumstances? Supposing the 50% who appeared to know the correct answer to the question about mosquitoes were also asked about the effect of male circumcision on HIV transmission? Would they be deemed to be well enough informed, or informable, to give their consent to be circumcised? And how about the other 50%?

If one of the HIV industry's insights is that people are illiterate, why do they not spend money on education and literacy, instead of pushing doctrinaire agenda that are infused with global politics, religion, pseudo-morality and the like? The aim is to reduce HIV transmission, but circumcision, on its own, doesn't reduce HIV transmission. In fact, you have to give those who undergo the operation a fairly complex message: circumcision only protects against HIV (if at all) if condoms are also used. Now, those who have been receiving the messages know all about condoms, at least, they know what they have been told. So if they don't already use them, circumcision is not going to help, and may do harm. And if they do use them, circumcision is of no advantage whatsoever. Would people who know that agree to be circumcised? Why?

Hasn't the HIV industry noticed the conditions in health services in countries like Uganda? Haven't they noticed that hospitals are not safe places to receive health services, particularly circumcisions and other operations? Don't they think that illiterate people with abysmal health services need accessible and safe healthcare? Despite this apparent lack of insight, all the industry can think about is male circumcision, prevention of mother to child transmission and a few other tricks. Never mind education and health. Preventing infections in mothers should be prior to mother to child transmission, which means non-sexually transmitted HIV needs to be investigated. But male circumcision is likely to increase transmission to mothers, which increases the likelihood of mother to child transmission.

The problem with spreading a mixture of truths, half-truths and lies is that you don't get to choose which ones you can take back, which ones people will believe, which ones they totally misunderstand, etc. What a mess. But hey, just think of the commercial opportunities! Given that married people and those in long term relationships contribute most to Uganda's epidemic, the take-home message of the video seems to be that Ugandan men are feckless and the women are promiscuous. Data collected about sexual behavior doesn't support those messages so the HIV industry says or implies that they are lying.

That's why I would suggest that the HIV industry programs treat Africans like a bunch of animals being rounded up to receive whatever they are handing out. It's hard not to conclude that those who receive this kind of treatment are not seen as humans and that human rights are not relevant. Would this happen to white, middle-class Westerners? Well, HIV, we are told, is mostly transmitted through male to male sex and intravenous drug use in Western countries, so circumcision is not relevant. But isn't that, in itself, very surprising? Isn't there something odd about the claim that HIV is almost always transmitted heterosexually in Africa, but nowhere else?

Gray says "This is completely unique in public health. We've never used surgery to prevent an infectious disease. The learning curve is steep"; would Westerners agree to undergo surgery, or to allow their children or infants to undergo surgery, because there may be some reduction in the risk of being infected with HIV? I believe most people would not give their consent, however informed. It's not just unprecedented, it's unethical to excise a healthy piece of flesh for an advantage that may not be realized until many years later, if at all. Nor would anyone be more likely to give their consent if they knew that about 75 operations need to be carried out to prevent one infection, and that's in controlled trial conditions.

One of the biggest flaws in the received view of HIV is the claim that it is (or was) spread by 'high-risk' groups. The majority of people infected in high prevalence countries don't appear to be members of any high-risk groups; they are not even all sexually active. The difference between Western countries and high prevalence African countries is that, in the former, HIV is mainly confined to a handful of risks, such as male to male sex and intravenous drug use; in the latter, HIV is not mainly confined to identifiable risks. But, rather strikingly, Africans are not generally aware of what could pose the highest risks of all, unsafe healthcare and cosmetic services. UN employees, tourists and others are informed about such risks, but Africans are not. Surgery to prevent an infectious disease is not just unique in public health; if informed consent is required, mass male circumcision is probably not even part of public health.

But the Ugandan article goes further: "the Permanent Secretary in the Ministry of Health, Dr Asuman Lukwago" says "should [circumcision] be proved [ineffective], the country will drop the method for other viable ones". Let's hope the PS is right. The Ugandan article also touches on the fact that in some parts of Kenya, where circumcision is widespread, HIV prevalence is high. This is also true of several other African countries and several tribes in Kenya. But the HIV industry has always managed to select the data that suits them and you rarely hear any complaints from politicians.

Another article finds that a program that aimed to circumcise 70,000 Kenyan men in a 30 day period only managed to achieve a total of 40,000. Apparently, the shortfall is partly due to heavy rains. Their target of about 1.1 million will require that they achieve at least 40,000 every month until the end of 2013, so let's pray for dry weather. The article also refers to a finding that around one third of men who are circumcised engage in sexual activity a few weeks after the operation, which means that they risk transmitting HIV if they are positive and being infected if their partner is positive. It also sounds like some of them think condoms are no longer necessary, even though one of the aims of the program is to reinforce the continued need for condoms after circumcision.

More surprisingly, the Kenyan article expresses doubts about the ability of Kenya's health services to meet demand. "Health workers are burdened and there are other priorities that compete", according to a clinical manager. But are the health facilities currently providing the service able to do so safely? Many people who became infected during clinical trials of mass male circumcision are thought not to have been infected through sexual activity. There are good reasons to suspect that health services in Kenya and other high HIV prevalence countries are risky places.

But are we even arguing about science here? Associations between circumcision and low HIV prevalence are easily balanced, perhaps even outweighed, by associations between circumcision and high prevalence. If evidence, however valid, is carefully sifted and selected for the bits that suit a particular purpose, what difference does it make how 'scientific' it is? There is a more important issue here which is highly pragmatic. How should people in countries being trageted by mass male circumcision programs react? What should they do? These questions are as vital for women as they are for men, for children as much as for adults.

Circumcision, and the HIV industry's broader obsession with sexual transmission of HIV, results in people not necessarily seeing the simple and effective steps they can take to avoid being infected and how they can protect their family and friends. They need to know about the risks that arise from unsafe healthcare and cosmetic procedures, indeed, anything that involves possible bloodborne infection.

Proponents of circumcision want us to believe that HIV is almost always transmitted through heterosexual sex, but only in African countries. Much of the epidemiological data collected does not support that hypothesis; so how could this virus be difficult to transmit through heterosexual sex, in theory and in practice, yet be almost always so transmitted in African countries? Scientists may be employed to collect and analyse the data, but who commissions the data? Who controls the money that pays for it? Who decides what should be published, how it should be presented and what is deserving of the attention of the press?

Whether you're a scientist or not, look at the tone in which some of these articles are written, look at the rhetoric; think of the economics behind circumcision and other public health programs; look at the politics behind the concentration on some diseases to the exclusion of most others; even take a look at the history of involuntary circumcision in Kenya or the far longer history of forced circumcision around the world. Doesn't everyone have the right to health, to healthcare, to choose what kind of healthcare they receive? From a pragmatic point of view, from the point of view of those who are not scientists, politicians, industrialists, careerists or whatever else, it's best not to be distracted by what many people seem to do with their science.

Tuesday, March 20, 2012

My first big shock when I started to follow HIV related issues in East Africa was that it was assumed almost all transmission was sexual in Africa (though nowhere else). Then, to 'work out' how this could possibly generate such massive epidemics, there was also the tendency to go from the number infected, or said to be infected, to the absurdly high levels of unsafe sexual behavior that would be needed to explain high levels of heterosexual transmission of HIV. There has never been any evidence that unsafe heterosexual sex alone could explain Africa's worst HIV epidemics. But all the 'work' to prevent infection appeared to concentrate on sexual transmission.

If not all HIV is transmitted sexually, many interventions that target sexual behavior, whether levels are real or assumed, will fail. Abstinence and other associated campaigns didn't even sound plausible before they were implemented, but enormous amounts of money was ploughed into them. Some equally dubious interventions were dreamed up and most probably also had little positive effect; as for any negative effects, these are unlikely to have been measured, let alone alluded to in the copious self-congratulatory literature that has emerged from what became the extremely lucrative HIV industry.

When circumcision was mooted as a possible intervention, it seemed to suffer from the above problem; it would, at best, protect against heterosexual transmission; it would not protect men who have sex with men, infants who are infected by their mothers or intravenous drug users. Indeed, it turned out that it wouldn't protect women either, and probably increases transmission from men to women. It will not reduce non-sexual transmission of any kind, including that through unsafe healthcare or cosmetic practices. Worse, in the sub-standard health facilities that ordinary Africans are forced to use, mass male circumcision programs might add to the problem, with men being infected in the health facility where the operation is carried out.

But those receiving circumcision related funding continue to insist on the effectiveness of such programs, shouting down any opposition, churning out figures which could be interpreted to show that male circumcision reduce transmission from women to men, but never actually engaging with the opposition. There are now so many problems with male circumcision as a strategy that the whole exercise to circumcise between 22 and 38 million African men should be suspended. There is so much disinformation and consequent misunderstanding that the campaign is unlikely to do any good and is in serious danger of doing a lot of harm. At best, it is just another neo-colonial excess of the kind that probably ensured that HIV would become the pandemic that it now is.

Kenya's Nairobi Star is currently doing a great job adding to the obfuscation that seems to pass for scientific journalism. The article 'Study Claiming Cut Does Not Inhibit HIV Rejected' makes a shaky start by incorrectly suggesting the study was not published or that its findings were refuted, or were even addressed by those promoting circumcision. The cited claims from the study are, in fact, correct, but they are only the tip of the iceberg. Interviewing those who would have a lot to lose if the circumcision program was suspended and asking their opinion is easy enough. But is it adequate journalism? Does the public really need more of the selective use of factoids to justify spending hundreds of millions of dollars on a campaign that is likely to be of so little benefit (at best)?

One commentator, Dr Alex Opio, even has the cheek to claim that "HIV incidence is also low among the circumcised people, which shows that the circumcision campaign is working". It doesn't show any such thing and Dr Opio should be well aware of this. Or would he also like to accept that the higher HIV prevalence among women is also a result of the circumcision campaign? Apparently sex (notice, not 'heterosexual' sex) accounts for only 76% of infections while 22% is now accounted for by MTCT; is that also a result of increased male circumcision resulting in higher rates of transmission to women, and thus to infants?

The most pathetic part of the ambassador's feeble article is the claim that "circumcision is also a gateway to a range of male reproductive health and HIV prevention services" such as "HIV counseling and testing, treatment of sexually transmitted infections, promotion of safe sex practices, condoms and information and tips on how to use them correctly and consistently". Is he hinting that it's all or nothing from now on, that men will only receive the sexual health services they need if they agree to be circumcised? Or am I reading too much into the word 'gateway'?

Expanding access to healthcare, as is being done in Senegal, would only be a good thing if those services were safe. But Senegal doesn't have anything like HIV prevalence levels found in Kenya, or even in Ethiopia. And countries where access to healthcare is relatively high, such as South Africa, Zimbabwe and Botswana, have some of the worst HIV epidemics of all. A study carried out in Malawi even found that HIV prevalence was highest closer to health facilities. Expanding healthcare sounds like a no-brainer until the issue of safety is considered; without ensuring higher levels of safety, expanding healthcare could increase transmission of bloodborne and other diseases, including HIV.

Saturday, March 17, 2012

If people don't have access to clean water, adequate sanitation and even hygiene and sanitation related education, it is not time to call in Big Pharma, well funded academic institutions or even massive NGOs. The thought of billions in aid money being made available for expensive technical solutions may be distracting, but water and sanitation related disease epidemics do not just disappear once a vaccine or two have been produced. Western countries have never eradicated endemic diseases through vaccines alone, nor do they keep epidemics at bay simply by developing more and more medicines. So why should vaccines be the first (and last) port of call for so many public health interventions?

This is not to say that vaccines do not have a part to play in reducing and even eradicating some diseases. It's just that vaccines on their own won't be enough if people lack access to clean water and sanitation. The idea that diseases can be picked off one by one for eradication by the mere production of a range of pharmaceutical products is naive; worse than that, the idea is uninformed by all that has been learned by public health experts over several decades. People who consume their own waste (and that of others) will continue to suffer from and die from easily avoided and treated conditions. Using and drinking contaminated water will ensure that people continue to contract all sorts of diseases, vaccines notwithstanding.

This type of technocentric view seems also to be applied to HIV, and perhaps other sexually transmitted diseases. Despite the stunning advances that have been made in antiretroviral drugs, many people still seem to cling to the view that drugs alone will eradicate them all, or at least the most fashionable and profitable ones.

Similarly, it has also been assumed that male circumcision will substantially reduce HIV transmission because it is 'more hygienic' (in addition to a multitude of other claims made to argue for the operation as a means of reducing infection with HIV and various sexually transmitted infections). But is circumcision really preferable to penile hygiene? If people are unable or unwilling to maintain basic levels of hygiene, to what lengths should public health programs go to ensure that lack of hygiene is not responsible for the transmission of diseases? What about people who don't wash their fingernails or who bathe in water contaminated with sewage?

Disturbingly, some of the arguments put forward for male circumcision have, at times, been advanced for female genital mutilation by those who are in favor of it, in particular hygiene, aesthetic appearance, the claims that the opposite sex prefers it and that it prevents masturbation and licentiousness. There may even be a case for claiming that female genital mutilation reduces HIV transmission, a poor case, but no worse than that for male circumcision.

For example, while proponents of mass male circumcision cite the fact that HIV is highest in the Luo tribe in Kenya's Nyanza province, among whom only about 16% are circumcised, HIV is lowest in Kenya's Somali tribe, among whom 100% of males are circumcised. But it is estimated that 100% of female Kenyan Somalis have undergone genital mutilation, compared to no female Luos. Those who hazard a guess at some causal mechanism to explain any reduction in HIV transmission as a result of male circumcision suggest that Langerhans's cells, which are common beneath the foreskin, may play some kind of role. But Langerhans's cells are also plentiful in female genitalia.

These are very unconvincing arguments for female genital mutilation. but it's hard to see why they constitute convincing arguments for mass male circumcision. There are also other tribes in Kenya where male circumcision is widely practiced, such as the Maasai and the Meru, among whom HIV prevalence is not exceptionally low. It has been suggested that improved penile hygiene may be as effective in reducing HIV transmission as circumcision is claimed to be. This has not attracted anywhere near the same level of funding. Yet improved hygiene and access to clean water and sanitation would be of overwhelmingly greater value than circumcising as many as possible of the 15% or so of Kenyans not already circumcised.

Wednesday, March 14, 2012

It may seem like the issue of male circumcision crops up a lot on this blog. But if there was ever an intervention ostensibly intended to reduce HIV transmission whose time had not come, circumcision is it. It may, under certain circumstances which have yet to be identified, reduce HIV transmission from females to males. But it is very likely to increase transmission from males to females. Females in African countries where mass male circumcision campaigns are being carried out are far more likely to be infected with HIV than men. Therefore, females face the greatest risks if these ill-advised campaigns go wrong.

The long term population effects for males and females investigated by this model are found not to be strongly linked and "there are many possible ways in which an intervention which reduces prevalence in males might nonetheless increase prevalence in females." Despite such potential drawbacks, the authors seem happy for these campaigns to continue, with some minor adjustments. Let's hope that those baying for mass male circumcision can find funding for the modifications the authors recommend in the estimated $1.5 billion figure being bandied about for a campaign that promises (threatens?) to circumcise 20-30 million African men.

Before it was acknowledged that male to female transmission might increase, it was assumed that females would be indirectly protected because there would be fewer HIV positive males in the population. But, in addition to facing increased direct risks from circumcised males, the indirect benefits hoped for may also be eroded by changes in sexual behavior, presumably influenced to some extent by people's beliefs. Some circumcised men already think they are protected from HIV; some women think circumcised men are protected; some men are only willing to be circumcised because they think it confers very high levels of protection; and women seem to have been railroaded into persuading partners to be circumcised under the misapprehension that it will mean the men will be protected.

The highly dubious but often repeated arguments in favor of circumcision were originally concocted for scenarios where it was adult males being circumcised, and those opting for the operation were HIV negative. But it's a game of moving goalposts and now, HIV positive men are also offered free circumcision in case denying them the operation might lead to 'stigma'. The arguments are also now being used for those who are too young to give consent for the operation and even for newborns, for whom even the dubious benefits are known not to be relevant. But at least the authors of the above paper admit that their simulation shows a relatively small overall effect of circumcision rollout.

An article entitled 'Male Circumcision and HIV Prevention - Insufficient Evidence and Neglected External Validity', asks if research carried out so far really does support the rapid scale up of mass male circumcision programs. The three trials used to argue for circumcision suffer from a number of biases and one of the issues circumcision enthusiasts don't seem keen to discuss is the fact that many of the participants who seroconverted don't appear to have been infected as a result of their sexual behavior. Male circumcision will not protect against non-sexually transmitted HIV, such as through unsafe healthcare (or during the circumcision operation), tattooing, dentistry, body piercing, etc.

Those arguing for questionable HIV reduction and reproductive health strategies often claim that circumcision, pre-exposure prophylaxis (PrEP), injectable Depo Provera, microbicides and others benefit women, or even that they are 'women controlled'. But in reality, control is being wrested from people, male and female. Circumcision seems to increase the risks that women face in several ways. The extraordinary folklore that has grown up around the strategy shows that African men and women have been taken in; how will ordinary people ever be in a position to question something that seems to have so much academic, institutional and financial clout behind it? It's a bit like the mythical 'cloak of invisibility', which leads wearers to do things they wouldn't otherwise have done, not realizing that they are fully visible.

Maybe all or most African men will rally to the HIV industry's call, lining up to be circumcised and then returing home to use condoms for as long as they are sexually active. Maybe women will be galvanized into compelling men to use condoms, something they haven't been able to do so far. But the authors questioning circumcision as a HIV reduction strategy conclude that: "The policy questions to be considered are not whether a link exists between male circumcision and reduced rates of HIV infection, but, rather, whether mass circumcision is (1) an ethical and safe public health choice, and (2) the most cost-effective use of limited resources." At best, the answer to these questions is 'not yet', at worst, a resounding 'no'.

Tuesday, March 13, 2012

Not that all British people contracting HIV abroad are sex tourists, but you might think that sometimes. The British HIV Association's HIV Medicine has a brief article about HIV infections contracted by British people when abroad. 2066 out of 13,891 (15%) are said to have been so acquired between 2002 and 2010. While only 22% of HIV infections in the UK are said to be a result of heterosexual sex, the figure is estimated to be 70% for those who acquire the virus abroad. Oddly, the article doesn't mention non-sexually transmitted infections. While these may not be so common in the US, where a sizable number of the infections may have been contracted, they could well be common in Thailand and South Africa, which are also said to the source country for many of the infections (particularly Thailand).

The article makes the following recommendation: "[That] HIV prevention and testing efforts be extended to include travelers abroad, and that sexual health advice be provided routinely in travel health consultations and in occupational health travel advice packs, particularly to those traveling to high HIV prevalence areas and destinations for sex tourism. Safer sex messages should include an awareness of the potential detrimental health and social impacts of the sex industry."

This could be compared with the advice found in the Lonely Planet travel guide - East Africa, 5th Edition: "Any exposure to blood, blood products or body fluids may put the individual at risk [of HIV infection]. The disease is often transmitted through sexual contact or dirty needles - vaccinations, acupuncture, tattooing and body piercing can be potentially as dangerous as intravenous drug use. HIV/AIDS can also be spread through infected blood transfusions; some developing countries cannot afford to screen blood used for transfusions. If you do need an injection, ask to see the syringe unwrapped in front of you. Fear of HIV infection should never preclude treatment for more serious medical conditions."

The only problem is that UNAIDS, WHO and others don't extend the above advice to Africans; the British HIV Association seem to be following their example in not extending it to British people traveling abroad. It's quite possible that the British people who are said to have acquired HIV abroad really did have unprotected sex, as the article claims. But it is also possible that some of them received medical treatment, possibly for a sexually transmitted infection, possibly in the kind of conditions that UN employees (but not Africans) are advised to avoid. 9% of the females infected abroad were thought to have been infected in Kenya and nearly 8% in South Africa. Infections probably acquired in Nigeria and Zimbabwe were also reported. If health facilities are risky for UN employees they are also risky for Africans, and even for visiting British people.

Donovan is a bit hopeful in thinking that WHO reviewed "all the best scientific research available." They reviewed some research, left out some and still found the data difficult to interpret. But not too difficult to decide in favor of advising that people continue using the method, with condoms, until more decisive research can be carried out. That might be understandable if Depo were the only form of birth control available or if injection was the only or best method method of administration; but neither are the case.

In fact, what AIDS-Free World, PPFA and WHO fail to mention is that all the data that was considered was about sexually transmitted HIV. Not all HIV is transmitted sexually, but it is usually assumed that all or most is transmitted through heterosexual sex in African countries. Neither condoms, Depo Provera, however administered, nor probably any other contraceptive method, protects against certain types of HIV transmission, such as through unsafe healthcare or cosmetic services. Indeed, high use of injections in healthcare facilities where safety standards are not very closely adhered to might be part of the problem; or it may have been part of the problem at one time.

Donovan asks "What if women at high risk of HIV hear that experts are concerned about injectable hormones, and choose to stop using them until researchers have come to definitive conclusions?" Well, as long as they use some other form of contraception, what if they do stop using Depo? Donovon goes on: "What if, as a result of that choice, many more women in countries with high rates of maternal mortality become pregnant?" One of the reasons why maternal mortality rates are high is because conditions in health facilities are extremely bad; so bad that many opt not to use them and rely on something that may or may not be a lot worse.

If AIDS-Free World, PPFA and even WHO are worried about maternal, infant or child mortality, choice of contraceptive method is really not the most important issue. Especially if the 'choice' to use injectable Depo could be exposing women to risk of infection with HIV and other diseases (or may have done in the past). The solution to the problem of unsafe healthcare is safe healthcare, not birth control. I suspect PPFA and the like have been imagining that they are 'saving' lots of women by persuading them to use their (the NGO's) favored method of birth control; but if healthcare facilities remain as appalling as they are now, even those follow current advice may still risk being infected with non-sexually transmitted HIV and other healthcare associated infections.

If women need more options, as Cullins argues, that should include non-hormonal methods, non-injectable methods, etc. Even Michael Sidibe of UNAIDS points out that women need safe contraceptive and HIV prevention options, but he rather piously mentions 'ownership' and 'management'. One of the reasons injectable Depo has been favored by those who promote it is because they themselves can 'own' and 'manage' it. Women just go to the health facility every three months. There may be a sense in which Depo is more 'female controlled' than male condoms, for example. But if women can't control men's use of condoms, injectable Depo Provera may well be the last method they should consider using; after all, you would be failing to follow WHO's advice if you used Depo even though your sexual partner refused to use a condom.

Both AIDS-Free World and PPFA seem to recognize that healthcare conditions are not particularly good in some countries. So why not warn people that they may be exposed to HIV and other diseases through their use of these facilities? If people don't recognize the risks they will not be able to avoid them. Whatever about the dangers of hormonal contraceptives per se, injections and other skin piercing practices are highly efficient modes of HIV infection, far more efficient than heterosexual sex. When healthcare conditions are poor, injections are best avoided. Low levels of maternal health and high maternal mortality are not primarily a matter of birth control method; women need safe healthcare and appropriate birth control methods, not whatever commodity NGOs like PPFA happen to be pushing.

Thursday, March 8, 2012

Probably in common with many bloggers, HIV in Kenya is my own take on things of interest to me that relate to HIV, development, Africa, health and various other subjects. I am not 'giving a voice to the voiceless', just saying what I think because few people or institutions that I know of are saying the same thing. Taking a keen interest in something does not necessarily make me an expert, but if I am wrong, surely I am more likely to be set right by airing my views in public, with arguments and citations that I feel support my views? In the process, sometimes I change my views imperceptibly (perhaps even to myself), sometimes I do so radically.

But one thing I will not do is leave what can be highly technical subjects to those who are seen as, and/or who see themselves as, experts. I may at times defer to them, but I also question them. This is because I have read many apparently well researched and well written papers, with mountains of citations and erudite passages, often published in respected, even venerated, peer-reviewed journals, whose conclusions seem to fly in the face of my own analyses, observations and experiences. We may not all have the same academic credentials, but we should have a lot in common in virtue of being humans. Yet, I constantly find myself reading 'scientific' papers that either state, imply or evidently assume that some humans are capable of behavior that would be beyond the ability, inclination or both, of most people.

There are so many overlapping groups who have been 'identified' as being at risk of infection with HIV, often mistakenly, that this approach is of very limited value on its own. Aside from at times stating, incorrectly, that 'everyone' is at risk, or is at equal risk, at other times the finger has been pointed at men, women, children, Africans, Haitians, gays, soldiers, teachers, young brides, older men, long distance truckers, immigrants, migrant laborers, prisoners, sex workers, clients of sex workers, intravenous drug users, victims of female genital mutilation, uncircumcised men, fishermen, widows, alcoholics, internally displaced people, sex tourists, sugar daddies, partners of sugar daddies, poor people, rich people, uneducated people, students, people with certain diseases, especially sexually transmitted infections, and the list goes on.

Almost all of those groups listed above are said to be at risk of infection with HIV because of some kind of sexual behavior, and some of them are indeed at risk, others may be at risk. But HIV is not always transmitted sexually. Aside from the more obvious intravenous drug use and mother to child transmission, there are additional non-sexual HIV risks that are rarely mentioned in the literature except to be denied or diminished. What I would really like to know is the relative contribution of non-sexual HIV transmission, especially from unsafe healthcare, and perhaps to a lesser extent from unsafe cosmetic practices. It could be true that unsafe healthcare plays a very minor role in serious HIV epidemics in Africa. But I don't believe that, especially when I read documents such as the Service Provision Assessment documents for Kenya, Uganda and other countries.

Similarly, there is much written about the potential effectiveness of conditional and unconditional cash transfers, particularly to young girls, mass male circumcision, pre-exposure prophylaxis, testing everyone (or at least 80% of people) in HIV endemic countries and treating everyone found to be infected, microbicides and various strategies, including abstaining from sex. Indeed, organizations involved in all sorts of activities, such as birth control, poverty, gender based violence, alcohol and drug abuse, reproductive health, religious practices, sex education, even selling commodities such as condoms, pharmaceuticals and various devices and services, all find their best market, sometimes their only market, in HIV. Some of these may be effective, even good value, some are probably not effective and others are harmful or potentially harmful.

Among the many disputes that I have been part of though my blogging are marketing of inappropriate pharmaceutical products, questionable ethical practices, especially in drug trials, dissemination of questionable data and information that affects peoples' health; I have also specifically raised questions about use of injectible Depo Provera hormonal contraceptive, strategies such as 'ABC' (abstain, be faithful, use a condom), pre-exposure prophylaxis in populations where it is unclear who is at risk of HIV infection and what kind of risks they face (whether they are sexual or non-sexual); and in particular, I have raised questions about mass male circumcision, over and over again. True, there are quite a number of recent papers about circumcision which make strong claims about its effectiveness. But there is also a wealth of literature that is more critical, much of which is ignored in the favorable papers.

In a word, the debate is highly polarized. There are those who only seem to concentrate on what they see as advantages in circumcising 30-40 million Africans, at vast expense; and there are those who keep asking questions about what seems like a lot of propaganda, and citing numerous possible disadvantages. Living in East Africa, I have heard people talking about circumcision and they have all been in the first group, those who only mention the advantages. As a result, many of the recipients of this information think they are already protected, being circumcised; many women seem to share this view. Uncircumcised men are, unsurprisingly, more reticent. But if the numbers we read are true, tens of thousands, even hundreds of thousands are turning up to be circumcised. It would be interesting to know what it was that convinced them and if they were convinced by propaganda, because there doesn't seem to be a lot else readily available.

This is not the first time I have cited something that has turned out to be questionable. I have also inadvertently drawn incorrect conclusions, even miss-cited sources and made other errors. Thankfully, either I have noticed and made amends, or someone has contacted me to let me know there is a problem. At other times, people are not particularly polite, perhaps because they have an axe to grind or some kind of interest, financial, political, personal, whatever. Nevertheless, I'd rather get a kick in the ass from someone who is right than a pat on the back from someone who is knowingly or carelessly peddling rubbish. And much though I hate to admit it, 'you would say that, wouldn't you' is a fallacy. Even if someone is saying something because it's their party line, and not because they always fight for their convictions, that doesn't mean they are wrong.

Even at risk of saying (or citing) something that turns out not to be true, I am going to continue objecting to what I believe to be wrong until I become convinced that it is not wrong. I have yet to be convinced that mass male circumcision will reduce HIV transmission, just as I have yet to be convinced that HIV is almost always transmitted through heterosexual sex in Africa. Therefore, I shall continue to express these views on my blog.

So, as yet, "All information concerning a user, including information relating to his or her health status, treatment or stay in a health facility is confidential." But it is high time to address the problem that many people either avoid finding out their status or avoid informing their partner once they know.

According to the act, the healthcare practitioner has a "right to a safe working environment that minimizes the risk of disease transmission and injury or damage to the health care personnel or to their clients, families or property". I wonder if this covers inadvertent infection with blood borne diseases through reuse or careless use of unsterile equipment? In the section entitled 'Promotion and advancement of public and environmental health', there is mention of legislation to be enacted by Parliament to provide measures for "Strengthening infection prevention and control systems including health care waste management in all health facilities".

Of course, healthcare transmitted HIV infections may rarely occur, as is claimed by UNAIDS. But it is possible that the Kenyan government is not prepared to leave the matter to chance, as some of the big players in the HIV industry have done so far.

One of the most striking aspects of these trials is that the figures purporting to show that such programs can reduce HIV transmission are those for relative risk reduction, not absolute risk reduction. While a 60% relative risk reduction may sound impressive, a 1.3% absolute risk reduction is not even statistically significant. Why are we being given selective and highly misleading data about circumcision if it is as important an intervention as we are told it is by its proponents?

The levels of misinformation being spread about male circumcision are astounding. Arguments for adult male circumcision have even been used for infant circumcision, although the claimed effects of adult circumcision have not been demonstrated for infant circumcision. 'Experts' extol the multiple virtues of circumcision, ignoring the lack of evidence for their claims, indeed, apparently blind to the entirely unscientific nature of many of the claims. After stating that "a circumcised [male organ] is definitely cleaner than an uncircumcised one" 'Dr' Khumbulani Moyo, Clinical Director of Population Services International goes on to say "Circumcised men are also more likely to be assertive sexually as awareness of a good body image is a very important factor in building self confidence." I wonder what his doctoral thesis was on; yoga perhaps?

Boyle and Hill note that the three trials purporting to show the effectiveness of circumcision were carried out in countries where it was already clear that HIV prevalence was higher among uncircumcised men. However, there are just as many countries where HIV prevalence is higher among circumcised men. They ask why the evidence to support a program that may aim to circumcise as many as 38 million men is so selective and point out that with less selective analysis, the program would not be supported. There are so many biases and inadequacies in the data that it can not be used to justify carrying out what is likely to be a dangerous, unnecessary and perhaps even counterproductive program.

It's hard to do this lengthy and well researched paper justice in a short blog post, but it's worth mentioning that one of the many flaws in the research is that non-sexual transmission of HIV was not reported. Quite a number of the men infected with HIV during the trials were probably not infected sexually and could have been infected through unsafe healthcare, perhaps even the treatment they received through taking part in the trial. Mass male circumcision enthusiasts claim that the operation reduces sexual transmission, but many men (and women) might face high non-sexual risks in addition to any sexual risks. But trials into circumcision and other HIV prevention interventions rarely seem to consider non-sexual risk.

There is a substantial body of evidence showing that male circumcision either doesn't reduce HIV transmission or even that it increases transmission. This evidence is not often mentioned by those whose aim appears to be to promote the strategy at all costs. In contrast, there is evidence that 'circumcising' women may be associated with some reduction in HIV transmission without this giving rise to the same enthusiasm for female genital mutilation. There is something of the crusader about the circumcision enthusiasts, something cabalistic in their methods. But what appears to be entirely lacking is science and logic.

While Pepin argues that the epidemic would never have got going without widespread colonial healthcare programs, and even with them it still took some decades, Timberg and Co. relegate everything about unsafe healthcare to a parenthetical comment. And though Pepin's argument becomes flakey when he claims that sexual behavior alone wouldn't have been enough to give rise to a serious epidemic, yet that it was enough to ensure that prevalence reached massive levels at some point, Timberg and Co. argue "it’s clear that colonial commerce created massive new networks of sexual interactions — and massive new transmissions of infections."

For them, it's quite simple: a hunter was infected by a chimp through a cut and went on to infect a sexual partner. As far as they are concerned, it was just a matter of there being a "population large enough to sustain an outbreak and a sexual culture in which people often have more than one partner, creating networks of interaction that propel the virus onward." For them, Kinshasa was that place. But while that city has been identified as the place where some of the earliest large scale transmission occurred, this does not mean all transmission, or even most transmission, was through heterosexual intercourse.

There is a problem with Kinshasa as a candidate for high levels of 'unsafe' sexual behavior: syphilis, the sexually transmitted infection (STI) that didn't bite. In 1958, nearly 100,000 men, all the men in the city, were screened for STIs; only 44 possibly had syphilis (and there were a few hundred with other STIs). Even some of those who possibly had syphilis may equally have been infected with the non-sexually transmitted yaws, which was too similar to distinguish.

In fact, trends in syphilis rates in many areas have gone in the opposite direction to trends in HIV prevalence. But syphilis rates do testify to at least two things; unprotected sex and poor sexual health facilities. In the few years before HIV was identified, these two factors came together in countries like Kenya, Tanzania and others in ways that may suggest when and where the real 'explosion' occurred. The highest HIV prevalence figures found in African countries were among sex workers, many of whom had been targetted by STI treatment and vaccination. Such rates have not since been found among this group. Significantly, in several non-African countries, HIV rates are not particularly high among sex workers unless they are also intravenous drug users.

Timberg and Halperin's argument doesn't work. HIV can be transmitted sexually but, as they and Pepin point out, it usually isn't. Pepin demonstrates very convincingly how unsafe healthcare programs, even ones that he himself was involved in, were required to enable the virus to infect huge numbers of people in a short space of time, something sexual transmission alone could not have done. But while Pepin doesn't successfully demonstrate how sexual behavior could take over from unsafe healthcare, Timberg and Halperin don't appear to demonstrate anything worth writing a whole book about.

The authors blame 'The Scramble for Africa', but without shedding any light on how various colonial maneuvers did, and continue to do, so much damage in former colonies. They and Pepin point a finger at 'urbanization', which is common in the HIV literature. But what, in particular, is it about colonization and urbanization that influence how a virus that is difficult to transmit sexually becomes a pandemic, and one driven primarily by sexual behavior if the HIV orthodoxy is to be believed? This is not merely a problem for historians: if the HIV industry continues to behave as if the virus is almost always heterosexually transmitted, non-sexual transmission will not be addressed, as it so urgently needs to be.

[This blog post is about Timberg and Halpern's article plugging their book, not on the book itself, which may take some time to acquire in East Africa. For more about non-sexually transmitted HIV, see the Don't Get Stuck With HIV site.